“I care so much it hurts.”
I was in the middle of my Trauma Nurse Core Course (TNCC) refresher. One of the instructors was giving a lecture about ethics, bringing up a co-worker who liked to say this line sarcastically. The whole lecture had an air of “we have to talk about this, so I’m going to be sarcastic about it.”
But that’s the problem. Being compassionate can be traumatic.
I have been really reflecting on the trauma of compassion. In my academic life, I took a class about trauma research this past semester that was completely eye-opening. In my professional life, a number of very traumatic events have been haunting me. And in my prayer, I have been feeling an invitation to greater compassion, seeing more clearly how Jesus suffers as I suffer and that He is calling me to do the same for His children.
I still think it is my greatest accomplishment of 7 years of nursing that I am not burnt out or so traumatized that I cannot function.
Nurses and other health care professionals experience both.
The New York Times recently had an article about how health care professionals experience post-traumatic stress disorder (PTSD) and burnout. The article brought up Navy nurse Dorothy Still who was captured by Japanese military during World War II. She was experiencing clear PTSD symptoms, which was unrecognized by the psychaitrist she saw. Even now, researchers are just starting to come to understand how health care professionals are at risk for PTSD and burnout from witnessing the pain and suffering of others.
Health professionals are at risk for both PTSD and burnout, but the two are distinct. PTSD includes symptoms such as disturbing dreams about a traumatic event, difficulty sleeping, irritability, and intrusive memories. Burnout is emotional exhaustion, depersonalization, and a lack of feeling accomplished.
To me, burnout out is a defense mechanism against PTSD. You cannot be traumatized by how much you care if you do not care at all. You will not experience the pain of another if you do not view them as a human being. Traumatic events will not haunt you if you do not think that they matter.
I think the burned out nurses, doctors, etc. I work with want to care. I sincerely do. I think they are emotionally exhausted from caring, and this is their defense against becoming completely wiped out and having PTSD symptoms.
PTSD is becoming a recognized risk of the job. Luftman et al. (2017) conducted a survey of pre-hospital and in-hospital health care professionals including paramedics, nurses, surgeons, and ER physicians, finding that 33% screened positive for diagnosable PTSD. Adriaenssens et al. (2012) noted that a traumatic event such as the death of a child put ER nurses at risk for PTSD. Lavoie et al. (2016) studied factors associated with resilience and susceptibility of PTSD, finding no association between gender, age or work experience. Any and every health care provider is one traumatic event away from potentially having PTSD.
And even if that health care professional does not recognize the trauma of being compassionate to the traumatized, the body does. One of the most interesting things I learned in this trauma research class is that The Body Keeps the Score, as the required reading was called. Even if a person says they are not affected, says they are fine, says they are coping, the body bears the brunt of remembering a trauma if the brain refuses to. As Dr. Bessel Van Der Kolk, a psychiatrist who has dedicated his life and research to understanding trauma, wrote in The Body Keeps the Score, “the memory of trauma is encoded in the viscera…in autoimmune disorders and skeletal/muscular problems.”
Milligan-Saville et al. (2017) studied emergency medical services (EMS) personnel, finding that those with PTSD symptoms were more likely to experience musculoskeletal pain, headaches, and gastrointestinal (GI) symptoms like nausea and abdominal pain. The authors adjusted for age, so this was not a factor in the manifestations of physical symptoms in response to PTSD.
Ongoing research is also looking at the connection of trauma to disease processes. Functional somatic syndrome diseases such as fibromyalgia (a chronic pain syndrome) and chronic fatigue syndrome (which sounds like its name, a chronic fatigue disorder) are controversial because the symptoms are mostly subjective. However, in a thorough meta-analysis of the existing literature, Afari et al. (2013) found that patients with a history of trauma are 2.7x more likely to have a functional somatic syndrome disease compared to non-traumatized persons.
Trauma plays a role in obesity as well. Sommer and colleagues (2018) also found that about 40% of persons with PTSD also had maladaptive eating habits. Van der Kolk (2014) noted that adverse childhood events (ACE) or traumatic events in childhood like child abuse are highly correlated with obesity. Van der Kolk (2014) told the story of an obese woman to drive this point home. The woman was sexually abused as a child and lost about 300lbs. She willingly gained the weight back when a co-worker hit on her as a defense mechanism.
This semester really challenged how I perceive illness. Part of it is that I am in the didactic portion of disease process and memorizing gram-negative and gram-positive bacteria, making undergraduate microbiology manifest again. But I have never critically thought about trauma as a risk factor for health. Now I wonder why I have not.
When I learned about the brain-body connections in my trauma class, including the relationship with somatic diseases, I had literally just learned about chronic fatigue syndrome at length the prior month. Trauma was never mentioned as a risk factor.
Why have I never learned about trauma being a risk factor for obesity before? Why have I never learned about trauma and somatic disorders? Why am I constantly lectured on self-care but never told that I might care so much that it hurts me? Why are lectures about PTSD told in a sarcastic manner when a 1/3 of my colleagues might be suffering from it? Why is the trauma of compassion not discussed!?
The medical community cannot change without learning about it, and I am convinced that we need to be educated on this topic.
But to be educated, we need to admit we are affected. We need to admit that sometimes we care so much it hurts. We need to admit that we suffer too.
Yet admitting that we suffer too is inherently shameful in the medical community. We are supposed to be masters of the human body and mind, not subject to it. At least, that is the impression we get from our training. We work make residents work 80 hour weeks. We push our students to their breaking points. We weed out “poor” students with good GPAs and great potential. Our training to become a health care professional who the world needs to be compassionate almost beats all compassion out of us. And even if we have a shred of it left when we graduate, we have a health care system that values efficiency over humanity and a million competing expectations.
So, here’s to the patients who have affected me, the ones I sometimes have disturbing dreams about, the ones I cared about so much that I hurt:
- To the young man who suffered a traumatic brain injury that was so severe he became an organ donor. My co-workers all say that the best outcome possible happened. It is true. I am so glad that your family decided for you to live on in other people. Your head injury was too great for you to live. I just mourn the loss of your young life and wish others would mourn with me too.
- To the elderly woman who was slowly dying in triage. I wish that we could have given you a room immediately. I really do. But letting you be in a bed in a semi-private room is all that we had. I hope you know that is all that we could offer you for what we had to give.
- To mother and father whose sobs filled the trauma bay after their son tried to hang himself. I wish I could convince all my self-harm patients how much they are loved. I wish you could meet them and convince them their life matters.
- To the elderly gentleman who was my first patient death. I really wanted you to live like we had chatted about when you were on the upswing. Thank you for teaching me that death in the hospital could still be good and sacred. You taught how to prioritize well.
- To the middle-aged woman who my friend and I worked on continuously for 2 hours before we knew the extent of your head injury from your accident. It was so hard to stand by and watch you slowly die. I know CPR would have done nothing and that praying for you and holding your hand at the end meant more than anything, but I still cried for you for hours. I wish we could have done something more.
- To the young boy who made a dumb mistake driving that killed his little sister. I had to lie to your sweet, scared face when you kept asking me about her. I understand that the police nor I could not tell you about her condition until the the investigation was complete but withholding that information and pretending not to know about her hurt me deeply. I wish you knew how much that tore me apart.
- To the mother who taught me how precious mothers and fathers are. Thank you for teaching me to not take mine for granted.
- To the daughter whose face I cannot forget when she saw her elderly father who shot himself. I wish that his psychology appointment was a day earlier and not scheduled for hours after he did this to himself.
- To the husband whose shock at seeing his young wife overtaken by tubes lingers in my memory. I remember being fascinating by the extent of her injury. You were fascinated in a completely different way. Thank you for asking me all those questions and helping me learn how to take care of families whose loved one has been injured.
- To the tough gang member who was shot in the torso who held my hand and looked into my eyes, begging not to die. I wish all those tough enemies of yours could have seen your humanity like I did.
- To the father who was bloodied and beaten by his son. Your pain broke my heart, but your continued love for your son taught me so much about God, even in our brief encounter. You had the face of Christ, and it was an honor to take care of you.
- To the mom who was in a horrific accident with your husband and son. I hate that your blood pressure was so low that we could not give you pain medications. I hate that you suffered so much and that the trauma probably continues to affect you as it does me years later. I cried that night because your son and my nephew share the same name. It was the first time in my trauma training that I saw trauma patients as people and not just patients. That name made me see you as my sister, and I mourned your accident as if you were my sister. I still squeeze my nephews and sister extra tight after taking care of you.
- To the mentally delayed elderly woman who we intubated. We did not know it was against your wishes. I hope you know how angry all of us were at your facility for not sending your DNR (do not resuscitate) paperwork. It was never our intent to have you suffer. We went on the little information we had when you arrived and our analysis of your critical condition. I hope you know that resident stayed hours past her shift to make sure your wishes were met and that the ICU attending opened an investigation of your facility so this never happens to anyone else. It was never our intent to hurt you. I hope you did not suffer.
- To the young man who wondered by he lived while his friend died. Opening up to you was the first time I really let myself be vulnerable with a patient in my young nursing days. I did not think as poorly of you as you did yourself. I hope our conversation helped you heal.
- To the elderly woman who lost her husband in a car accident whose only goal in the hospital was to heal so she could attend his funeral. I still remember your name, and that’s not a very common thing for me. You met me when I was a new nurse, and it is you who I hold in my heart when I remember all these other trauma victims. You should be that it is possible to be resilient and heal. You remind me why my job is vital, and how sometimes caring does not hurt. You taught me that my compassion can also help heal both others and myself.
I know the risks of compassion. I may be burnt out one day. I might have PTSD and need medications. I may hurt. I may cry. I may suffer.
But compassion means “to suffer with.” If this is what it takes to care, it is a risk I am willing to take. Compassion might hurt, but it also heals.
As C.S. Lewis beautifully wrote,
“To love at all is to be vulnerable. Love anything and your heart will be wrung and possibly broken. If you want to make sure of keeping it intact you must give it to no one, not even an animal. Wrap it carefully round with hobbies and little luxuries; avoid all entanglements. Lock it up safe in the casket or coffin of your selfishness. But in that casket, safe, dark, motionless, airless, it will change. It will not be broken; it will become unbreakable, impenetrable, irredeemable. To love is to be vulnerable.”
– C.S. Lewis, The Four Loves
Whenever I am hurting because I am caring, I look to Jesus. It might sound corny, but it’s true. He was always vulnerable. He always saw other people as being worth loving and caring for. He suffered with others willing. Those are a hard characteristics to imitate.
But I have found as I have been more generous with my care than I think prudent, I have found more life, joy, and satisfaction in work than I have. Yes, I do cry, mourn, and suffer, but I also have found myself closer to the One who teaches me compassion. And His presence is healing, both to me and others.
To love at all is to be vulnerable. My patients are already in a vulnerable state when I met them. To reach out in mutual vulnerability is a gift. To love another person in their vulnerability is to love as Jesus does.
As Victor Hugo wrote in Les Miserables, “to love another person is to see the face of God.”
The Deepest Well: Healing the Long-Term Effects of Childhood Adversity – Dr. Nadine Burke Harris (currently reading!)
The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma– Dr. Bessel Van der Kolk
Adriaenssens, J., De Gucht, V., & Maes, S. (2012). The impact of traumatic events on Emergency Room nurses: Findings from a questionnaire survey. International Journal of Nursing Studies, 49(11), 1411-1422.
Afari, N., Ahumada, S. M., Wright, L. J., Mostoufi, S., Golnari, G., Reis, V., & Cuneo, J. G. (2013). Psychological trauma and functional somatic syndromes: a systematic review and meta-analysis. Psychosomatic Medicine, 76(1), 2-11.
Lavoie, S., Talbot, L. R., Mathieu, L., Dallaire, C., Dubois, M. F., & Courcy, F. (2016). An exploration of factors associated with post‐traumatic stress in ER nurses. Journal of Nursing Management, 24(2), 174-183.
Milligan‐Saville, J. S., Paterson, H. M., Harkness, E. L., Marsh, A. M., Dobson, M., Kemp, R. I., … & Harvey, S. B. (2017). The amplification of common somatic symptoms by posttraumatic stress disorder in firefighters. Journal of Traumatic Stress, 30(2), 142-148.
Sommer, J. L., Mota, N., & El‐Gabalawy, R. (2018). Maladaptive eating in posttraumatic stress disorder: A Population‐based examination of typologies and medical condition correlates. Journal of Traumatic Stress, 31(5), 708-718.
*details and names omitted to respect patient privacy